Thermal ablation is an effective treatment for hepatocellular carcinoma (HCC), the most common type of primary liver cancer. However, early recurrence (ER) after treatment for HCC remains a significant challenge. This study aimed to (1) establish a robust and reproducible pipeline for prognostic model development, and (2) apply this pipeline to develop a preliminary model predicting ER in a Western HCC-cohort. Clinical data and contrast-enhanced pre- and post-ablation CT-scans from the Dutch multicentre PROMETHEUS cohort were used. Predictors included clinical characteristics, radiomics predictors, deep learning (DL) based predictors from two pre-trained models (ResNet18 and VGG16), and the minimal ablation margin (MAM). Cox regression models were constructed using principal component analysis (PCA) and regularised predictor selection (LASSO). Model performance was internally validated using bootstrapping and evaluated with the concordance index (C-index), calibration plots, and decision curve analysis. Using the developed pipeline, several individual and combination models were developed. The highest C-index in the validation sets was achieved by the model incorporating radiomics predictors and the MAM, which was trained on data from 68 patients (C-index = 0.63, 95% CI: 0.44 – 0.79). Despite promising performance in training sets, all models showed signs of overfitting and limited calibration in unseen data. The pipeline adheres to current guidelines and supports further refinement and validation. An externally validated prognostic model could help personalise treatment and follow-up strategies after thermal ablation in western HCC patients.

Purpose Manufacturer’s predictions of ablation zone dimensions are the current directives for treatment planning in thermal ablation, while they are mostly based on ex vivo experiments making its reliability questionable. The aim of this study is to determine the correspondence in dimensions, volume, shape and overlap of the manufactures’ predicted with the clinically realized ablation zones following thermal ablation of hepatocellular carcinoma (HCC). The secondary objective is to determine the effect of tumor- and liver characteristics on this correspondence.
Methods Data was retrospectively collected from two prospective studies. A registered pre-ablation and post-ablation computed tomography scan with liver, tumor and ablation zone segmentations were available for analysis. Needle position reconstruction was performed based on image visual assessment (e.g., gas formation, tumor location and subcapsular hemorrhage) using in-house developed software. The dimensions of the predicted ablation zone were derived from the manufacturer’s chart corresponding to treatment settings used during ablation. The long axis diameter (LAD), short axis diameter (SAD) and volume of the realized and predicted ablation zone were compared. The overlap was determined using the Dice similarity coefficient (DSC) and the average surface deviation between the realized and predicted ablation zone. The effect of tumor location, vascular proximity and liver cirrhosis on the overlap was quantified using the DSC and average surface deviation.
Results Nineteen patients and 21 ablations were included for analysis. The median realized volume did not significantly differ from the predicted volume, 25.7 cm3 and 22.6 cm3 respectively (p = 0.526). The median LAD and SAD of the realized ablation zone differed significantly from the manufacturer’s prediction (51.9 mm vs 40.0 mm, p<0.001 and 36.9 mm vs 35.0 mm, p<0.001 respectively). The predicted ablation zone corresponds to the realized ablation zone with a mean DSC of 0.73 and mean average surface deviation of 3.04 mm. Tumor location and vascular proximity did not affect the overlap between the realized and predicted ablation zone. The effect of liver cirrhosis was not assessed due to a low sample size of HCC in a non-cirrhotic liver (n=2).
Conclusion The manufacturer’s predicted volume of liver ablation zones corresponds well to the clinically realized ablation volume. However, the LAD and SAD are underestimated by the manufacturers. The shape and overlap of the predicted and realized ablation zone were sufficient. Further studies evaluating the effect of tumor- and liver characteristics on the correspondence of the predicted with the realized ablation zone with a larger patient cohort is needed.

Introduction The objective of this research is to assess whether there is a correlation between quantitatively assessed ablation margins and the occurrence of local tumor progression (LTP) using dedicated image processing software.
Methods 28 patients with 45 de novo HCCs treated with percutaneous thermal ablation, e.g. radiofrequency ablation (RFA) and microwave ablation (MWA) between January 2014 and March 2019 were retrospectively included. Semi-automated segmentation of the liver and the ablation zone, manual segmentation of the tumor, and semi-automated registration of pre- and postprocedural contrast enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) images was performed using in-house developed software deLIVERed. The image processing results were used for quantitative analysis of the minimal ablation margin (MAM) and the ablation margin surface area. The outcome of the quantitative analysis was compared to LTP occurence.
Results Image processing of the scans of 39 of the 45 tumors was feasible. 5/39 tumors developed LTP. Based on quantitative analysis, thermal ablation was insufficient in 29/39 tumors. Of these 29 tumors, 4 developed LTP. The median MAM for the LTP group and no LTP group was -4.6 and -1.7 mm, respectively. There was no clear correlation between the MAM and LTP occurrence.
The median tumor surface area exposed to insufficient margins was 28.9% and 7.7.% with and without development of LTP, respectively.
Conclusion Quantitative analysis of postablation images can provide insight in ablation margins and the development of LTP. The ablation margin surface area provides additional information to the MAM. However, additional research is needed in order to further investigate the implications of ablation margin surface area.